Patient authorization for release of medical ... - Penn State Health 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Patient Information section. Enter your name, date of birth, medical record number, phone number, and email address.
3. In the Reason for Request section, select the appropriate option that describes why you are requesting the information.
4. Authorize a specific employee or agent by writing their name in the designated field and check the relevant options regarding what healthcare information can be discussed.
5. Complete the Addressee Field with the name and address of the person or entity to whom you want to release or receive information.
6. Choose your preferred format for receiving medical information from the options provided.
7. Specify which types of medical records you are requesting by checking the appropriate boxes and listing their dates of service.
8. Sign and date the form at the bottom. If someone else is signing on your behalf, indicate their relationship to you.

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